Form

YWAM Madison Summer 2012 Outreaches
Thank you for applying to join us in on outreach this summer!

This application could take 20-45 minutes to complete. You should have the following information available: your passport, emergency contact details, health insurance information and health history, home church and pastor details, and information about any previous missions experience If you need help completing the application or would prefer it to be emailed to you, please contact us at outreach@ywammadison.org. For your application to be processed, the following must be received:
1. This Application Form
2. Your non-refundable registration fee: $35 per individual or $45 per married couple. (Please make checks payable to YWAM, or pay online with paypal here )
3. Two (2) completed Confidential Evaluation Reference Forms. These reference forms may be completed online, emailed, or printed and mailed to your references. Request your references to complete the form online, mail or fax it DIRECTLY TO YWAM. If you are under 18, one reference form must be filled out by a parent. For applicants under age 18, one notarized parental release form for outreach mailed to YWAM, PO Box 8503, Madison, WI 53708. Here is a link to that form: http://www.ywammadison.org/wp-content/uploads/2010/03/access-parents-waiver.pdf
We recommend typing your answers to the longer questions in a separate word processor in case your connection is lost during the submission process.
Applying for:*
Basic Information:
Full Name*
First Name Last Name
Birthday:*
Month Day Year
E-mail*
Phone Number*
- Area Code Phone Number
Cell Phone Number
- Area Code Phone Number

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Current Mailing Address (if different)

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

What is the best way to contact you:*

Email Facebook Cell phone Home phone
Upload Recent Photo: (max size 200 KB)
Passport:
Country of Citizenship:*
Passport Number:*
Issue Date:*
Month Day Year
Expiration Date:
- Month - Day Year
City and Country of Issue:*
Visa type: (if currently holding a USA visa)
Issue Date:
Month Day Year
Expiration Date:
- Month - Day Year
City and Country of Issue:
In Case of Emergency Contact:
Emergency Contact Full Name*
First Name Last Name
Relationship:*

Mother Father Friend Other

Emergency Contact's Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Emergency Contact's Phone Number*
- Area Code Phone Number
Emergency Contact's Cell phone
- Area Code Phone Number
Emergency Contact's E-mail
Marital / Family Status
I am...*
Will your spouse join you?*
Spouse's Full Name
First Name Last Name
Spouse's Birthdate:
Month Day Year
Do you have children?
Will your children join you?
Children's Names, Ages, Sex:
Criminal Record:
Have you ever been convicted of a felony?*
If yes, please explain: (when, where)
Have you ever been convicted of a sexual crime?*
If yes, please explain: (when, where)
Financial Information:
If you are accepted on this team, how will your expenses be paid?
Home Church Information:
Church Name:*
Denomination:*
Church Phone Number
- Area Code Phone Number

Church Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Pastor's Name*
First Name Last Name
Personal Reference - Pastor or church leader who knows you (if different from above):
Personal Reference - Pastor's or church leader's phone number:
Personal Reference - Pastor's (or church leader's) email address:
How long have you attended?*
How long have you been a Christian?*
Missions Background and Interest:
How did you hear about Youth With A Mission? About YWAM Madison? (Check any that apply.)*

Friend ywam.org ywammadison.org ywambases.org or ywamdts.org Facebook Google/other search Church Conference College None of the above
Have you had any previous experience with YWAM?*
If so, when and where?
Are you interested in further missionary or Bible training?*

Discipleship Training School Bible School for the Nations School of the Bible Other University of the Nations Course(s) None
Have you had any other previous missions experience?*
If yes, please describe and note whether this was a positive or negative experience.
Work Experience:
Please list your two most recent occupations. (If not applicable, please type "NA.")
Company:*
Position:*
Beginning:
Month Day Year
Ending:
Month Day Year
Company:
Position:
Beginning:
Month Day Year
Ending:
Month Day Year
Please list any other areas of training or work experience. (If not applicable, please type NA:*
Education Experience:
What grade level have you completed of Secondary/High School?*
When did you graduate?
Are you currently in college?*

Yes No
Name and address of institution:
If you are currently a student, what is your academic focus?
Spiritual History and Christian Life
Describe your current relationship with the Lord. What has been your greatest help and hindrance in your relationship with God in the past six months?*
Areas of Involvement
What expectations do you have for this outreach?*
What are your personal areas of strength, experience, or interest? (check all that apply)*

Administration Activities/Games Auto/diesel mechanics Children's ministry Construction Cross cultural understanding Discipling Exercise activities Hospitality Intercession prayer Leading discussions Leading intercession prayer Leading worship Meal/snack coordination One-on-one discipleship Overseeing transportation Performing arts Photography Teaching Writing / Communication
Write your three most preferred areas from the list above:*
Write your three least preferred areas from the list above:*
Have you ever taught before? If so, for whom and on what topics?*
In thinking ahead about this trip, what are you most excited about?*
In thinking ahead about this trip, what are you most concerned about?*
Do you have any other concerns or questions for us?*
Confidential Health Form
If you do not have health insurance, please let us know. Every participant is required to have basic health insurance that covers international travel while on outreach.
Medical Insurance Company:*
Policy Number:*
Phone:*
Does your insurance cover you outside of your home country or the United States?*
Personal Health History
Please answer all questions. Comment on all positive answers in the space below. Your answers will remain confidential.
Do you now have, or have you ever had, any of the following?*

Skin conditions Eye trouble Ear trouble Head injury Recurrent headaches Epilepsy Fainting spells Mental or nervous disorders Weakness Paralysis Insomnia Shortness of breath Hay Fever, Asthma Stomach/Duodenal Ulcer Gall Bladder problems Heart trouble Intestinal trouble High blood pressure Low blood pressure Recurrent diarrhea Diabetes Rheumatism/Arthritis Kidney Disease Back problems Jaundice Dislocation of Joints Hepatitis Anemia Broken bones Venereal Diseases Chickenpox Tuberculosis Measles Mumps Eating disorders Anorexia Nervosa Bulimia Tumor/Cancer HIV/AIDS Other None of the above
Have you had the following surgeries?*

Tonsillectomy Appendectomy Hernia repair Other-specify No Surgeries
Allergies:*

Penicillin Sulfonamides Food - specify below Other - specify below No known allergies
Are you currently pregnant?*

Yes No
Use this space to explain any positive answers above:
Do you have any other health conditions or concerns?*
What is your blood type?*
How would you rate your overall health?*
Are you currently taking any medication?*
If yes, please specify:
Please check the following that apply to you:*

I am currently undergoing medical supervision I have special dietary needs I have a history of emotional instability or psychiatric treatment I have physical handicaps or health conditions which require special attention I am unable to perform reasonably strenuous work on a daily basis I am unable to walk 3-4 miles per day None of the above
If you checked any of the above statements, please explain:
Have your relatives ever had any of the following:*

Tuberculosis Diabetes Kidney Disease Heart Disease Arthritis Stomach Disease Asthma, Hay Fever Convulsions, Epilepsy None
If yes, please explain and give their relationship to you:
Consent for Treatment
In the event of injury or illness of the undersigned (Applicant) while in association with YOUTH WITH A MISSION, INC., I/we hereby agree to the performance of such treatment, anesthetics, and operations as, in the opinion of the attending physician, is deemed necessary.
Electronic Signature (type your full name):*
Today's Date:*
Month Day Year
Parent/Legal Guardian's Electronic Signature (if Applicant is under 18):
Today's Date:
Month Day Year
Liability Release
I/we hereby release YOUTH WITH A MISSION, INC., its agents, employees, and volunteer assistants from any liability whatsoever arising out of an injury, damage, or loss which may be sustained by the undersigned (Applicant) during the course of involvement with YOUTH WITH A MISSION, INC.
Electronic Signature (type your full name):*
Today's Date:
Month Day Year
Parent/Legal Guardian's Electronic Signature (if Applicant is under 18):
Today's Date:
Month Day Year
Signature of Agreement
I certify that all information in the application is complete and accurate. I understand that if any information given is found to be false it could result in my removal or exclusion from the course. If accepted by Youth With A Mission, I will abide by the spirit, rules, and schedule of the program. I understand that payment of required tuition fees must be made upon or before arrival. I am fully aware of my financial obligation, both to the Lord and to the students and staff at Youth With A Mission. I therefore commit myself to paying all personal expenses incurred during my involvement with Youth With A Mission.
I agree to all of the above statements.*

Yes
Applicant's Electronic Signature (type your full name):*
Today's Date:*
Month Day Year
Parent/Legal Guardian's Signature (if Applicant is under 18):
Today's Date:
Month Day Year
When you are ready to submit your responses, please click "Submit." (You may wish to copy/paste your longer responses in a word processor in case your connection is lost during the submission process.)
After you click submit, you will be taken to a new page. If the page appears blank, scroll to the top. It should say "Thank You" or will let you know if you have not answered all the required questions.
You will also receive an automated email to the address you provided. If you have any problems submitting your application, or do not receive a confirmation email, please check your junk mail folder and then contact us at ywam@ywammadison.org.
Should be Empty:

YWAM Madison Summer 2012 Outreaches

Basic Information:

Passport:

In Case of Emergency Contact:

Marital / Family Status

Criminal Record:

Financial Information:

Home Church Information:

Missions Background and Interest:

Work Experience:

Education Experience:

Spiritual History and Christian Life

Areas of Involvement

Confidential Health Form

Personal Health History

Consent for Treatment

Liability Release

Signature of Agreement